Evidence-Based Reviews

Answers to 7 questions about using neuropsychological testing in your practice

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What assessments are available to you? How do findings inform your care of patients?


 

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Neuropsychological evaluation, consisting of a thorough examination of cognitive and behavioral functioning, can make an invaluable contribution to the care of psychiatric patients. Through the vehicle of standardized measures of abilities, patients’ cognitive strengths and weaknesses can be elucidated—revealing potential areas for further interventions or to explain impediments to treatment. A licensed clinical psychologist provides this service.

You, as a consumer of reported findings, can use the results to inform your diagnosis and treatment plan. Recommendations from the neuropsychologist often address dispositional planning, cognitive intervention, psychiatric intervention, and work and school accommodations.


Probing the brain−behavior relationship

Neuropsychology is a subspecialty of clinical psychology that is focused on understanding the brain–behavior relationship. Drawing information from multiple disciplines, including psychiatry and neurology, neuropsychology seeks to uncover the cognitive, behavioral, and emotional difficulties that can result from known or suspected brain dysfunction. Increasingly, to protect the public and referral sources, clinical psychologists who perform neuropsychological testing demonstrate their competence through board certification (eg, the American Board of Clinical Neuropsychology).

How is testing conducted? Evaluations comprise measures that are standardized, scored objectively, and have established psychometric properties. Testing can performed on an outpatient or inpatient basis; the duration of testing depends on the question for which the referring practitioner seeks an answer.

Measures typically are administered by paper and pencil, although computer-based
assessments are increasingly being employed. Because of the influence of demographic variables (age, sex, years of education, race), scores are compared with normative samples that resemble those of the patient’s background as closely as possible.

A thorough clinical interview with the patient, a collateral interview with caregivers
and family, and review of relevant medical records are crucial parts of the assessment. Multiple areas of cognition are assessed:
• intelligence
• academic functioning
• attention
• working memory
• speed of processing
• learning and memory
• visual spatial skills
• fine motor skills
• executive functioning.

Essentially, the evaluation speaks to a patient’s neurocognitive functioning and cerebral integrity.

How are results scored? Interpretation of test scores is contingent on expectations of how a patient should perform in the absence of neurologic or psychiatric illness (ie, based on normative data and performancebased estimates of premorbid functioning).1 The overall pattern of intact scores and deficit scores can be used to form specific impressions about a diagnosis, cognitive strengths and weaknesses, and strategies for intervention.

Personality testing. In addition to the cognitive aspect of the evaluation, personality measures are incorporated when relevant to the referral question or presenting concern.

Personality tests can be broadly divided into objective and projective measures.
Objective personality measures, such as the Minnesota Multiphasic Personality
Inventory-Second Edition, require the examinee to respond to a set of items as
true or false or on a Likert-type scale from strongly agree to disagree. Responses are then scored in standardized fashion, making comparisons to normative data, which are then analyzed to determine the extent to which the examinee experiences psychiatric symptoms.

As part of testing, patients’ responses to ambiguous or unstructured standard
stimuli—such as a series of drawings, abstract patterns, or incomplete sentences—
are analyzed to determine underlying personality traits, feelings, and attitudes.
Classic examples of these measures include the Rorschach Test and the Thematic
Apperception Test.

Personality measures and psychiatric testing are designed to answer questions
related to patients’ emotional status. These measures assess psychiatric symptoms and diagnoses, whereas neuropsychological measures provide an understanding of patients’ cognitive assets and limitations.


7 Common questions about neuropsychological testing

1 Will my patient’s insurance cover these assessments? The question is common from practitioners who are considering requesting an assessment for a patient. The short answer is “Yes.”

Most payers follow Medicare guidelines for reimbursement of neuropsychological
testing; if testing is determined to be medically necessary, insurance companies often cover the assessment. Medicaid also pays for psychometric testing services. Neuropsychologists who have a hospital-based practice typically include patients
with all types of insurance coverage. For example, 40% of patients seen in a hospital are covered by Medicare or Medicaid.2

A caveat: Local intermediaries interpret policies and procedures in different ways,
so there is variability in coverage by geographic region. That is why it is crucial
for neuropsychologists to obtain preauthorization, as would be the case with other medical procedures and services sought by referral.

Last, insurance companies do not pay for assessment of a learning disability. The
rationale typically offered for this lack of coverage? The assessment is for academic, not medical, purposes. In such a situation, patients and their families are offered a private-pay option.

2 What are the indications for neuropsychological assessment? Psychiatric practitioners are one of the top medical specialties that refer their patients for neuropsychological testing.3 This is because many patients with a psychiatric or
neurologic disorder experience changes in cognition, mood, and personality. Such
changes can range in severity from subtle to dramatic, and might reflect an underlying disease state or a side effect of medication or other treatment. Whatever the nature of a patient’s problem, careful assessment might help elucidate specific areas with which he (she) is struggling—so that you can better target your interventions. Table 1 lists common reasons for referring a patient for neuropsychological evaluation. Throughout this discussion, we describe examples of clinical situations in which neuropsychological testing is useful for establishing a differential diagnosis and dispositional planning.

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